The 2020 HLTH VRTL conference focused on how the COVID-19 crisis is accelerating trends that are transforming healthcare. In this article, I will describe the picture painted by the speakers of what the soon-to-be post-COVID health care world will look like.
I viewed the conference through my multifocal lens as a financial analyst, consultant, and patient and in keeping with my mission at Your Autoimmunity Connection, I kept one question in mind:
How could these accelerating post-COVID trends help patients with the subset of chronic inflammatory diseases with which the organization is most concerned: autoimmune and autoinflammatory disorders?
In Part 1 of this story, I described how COVID-19 has accelerated the use of telemedicine and remote patient monitoring. At the same time, it has speeded the migration from FFS by showing that a VBC reimbursement model can be a more reliable revenue stream for practices in disruptive times. These disruptor-driven trends have also spurred new primary care delivery models and consumer competition for the digital front door as described below. Companies highlighted in Part 1 were Amwell, Oscar Health, Massachusetts General Physicians Organization, and Aledade.
Novel, experimental primary care delivery models are emerging from inside and outside the current system. Not only big players (payers, providers, practice systems, and innovative employers), but also DTC online and walk-in acute care, “doc-in-a-box” online providers, drugstore, retail, and tech giants are all competing to be healthcare digital front doors.
It has been widely recognized for delivering high-quality healthcare at a low cost through an integrated delivery system model.
Jaewon Ryu, the President and CEO of Geisinger, said,
“Primary Care is the front door and it is how we drive affordability. We have been on a journey during the last three years on which we have been redesigning primary care. We believe there is an opportunity to introduce different flavors for those with multiple chronic conditions.”
As a large integrated delivery system, Geisinger has already developed products and services that could potentially help autoimmune patients, such as:
These are obvious targets for geriatric populations, but what about other chronic conditions that could benefit from home visits? That includes more severe autoimmune and autoinflammatory conditions, including chronic fatigue and post-viral (led by post-COVID) syndromes.
One Medical is a membership-based, technology-powered primary care model-of-care. It offers seamless digital health and inviting in-office care. The offices are convenient to where people work, shop, live, and go online. Their vision is to delight millions of members with better health and better care while reducing costs. Its mission is to transform health care for all through a human-centered, technology-powered model.
Their suite of services goes beyond the traditional primary care to include
These types of services give patients more convenient access.
Amir Dan Rubin, CEO of One Medical, explained,
“We are trying to transform healthcare through our modernized primary care approach and simultaneously address the needs of key stakeholders.”
He continued,
“We have created a staff model, HMO-like approach hidden in concierge sheep’s clothing. We have all salaried primary care providers. We have built our own software using machine learning to route the messages to virtual team members. In addition, we get reimbursed at an organizational level through conventional insurance. But we have also built the underlying incentives to deliver value-based, coordinated care.”
Improvements in care collaboration and coordination, along with a more preventive mindset related to value-based care (VBC), could benefit autoimmune patients. However, care delivery models must to choose to focus on them.
One Medical’s chronic disease list, as usual, omits mention of autoimmune, autoinflammatory, and immune-related chronic inflammatory conditions. Until such conditions are more than an afterthought, these primary care innovations are unlikely to improve autoimmune/autoinflammatory care. Even though improved care for these types of patients could be a competitive edge for new companies if they seize the opportunity.
Firefly Health is a virtual-first, primary care, behavioral health, and system navigation service. Their care teams include the following:
Their service offerings include same-day appointments, video visits, quick prescription refills, and more time with providers.
Fay Rotenberg, CEO of Firefly Health sees primary care as “bonding, steering, and health care fiduciary.” She says,
“We are transforming from a reactive, transactional, doctor-centered model, towards a proactive, personalized, digitally-enabled approach that supports healthy behaviors to drive better outcomes and lower costs. Our mission is to provide half-priced healthcare that is twice as good clinically and emotionally.”
Firefly Health was designed with the consumer in mind so it is easy to use. First, download the app, then connect with your care team who can help you in person, virtually, and via chat.
Their tech-enabled digital care platform, Lucian™, is built to track users’ care over time. For diagnostic testing, Firefly has an extensive, curated network of partners, some of which offer in-home testing. In addition, their teams can manage chronic diseases such as diabetes and high blood pressure. For more serious conditions, they partner with specialists.
The Firefly Health tech-enabled digital care platform and coordinated care teams offer elements that could be directed to help autoimmune and other chronic immune disorder patients better manage their daily health issues.
I can imagine how Firefly Health’s proactive personalized app could expand its functionality to help autoimmune patients with lifestyle modifications that could lower stress levels and reduce flares. But there’s no mention of chronic fatigue or autoimmune/inflammatory on their website. Instead, it’s just the usual mention of anxiety, diabetes, and high blood pressure as examples of chronic conditions.
They already have behavioral health specialists on care teams, and as we know, mental health issues, especially anxiety, loom large in autoimmune patients. Maybe mental health is the wedge to get Firefly Health to focus on immuno-inflammatory disease patients, too.
Will community pharmacies be the next neighborhood healthcare destination, an increasingly digital front door to more than prescription and OTC products?
Walgreens is part of the Retail Pharmacy USA Division of Walgreens Boots Alliance, Inc., a global leader in retail and wholesale pharmacy. They operate more than 9,000 retail locations across America, Puerto Rico, and the U.S. Virgin Islands. Walgreens is considered a neighborhood health destination serving approximately 8 million customers each day.
Walgreens pharmacists provide a wide range of pharmacy and healthcare services. To best meet the needs of customers and patients, Walgreens offers a true omnichannel experience, Their platforms bring together physical and digital health care delivery mechanisms. They are supported by the latest technology to deliver high-quality products and services in local communities nationwide.
Alex Gourlay, the Co-Chief Operating Officer at Walgreens, thinks that
“Putting together the family doctor and the local pharmacist with HIPAA-compliant health information and providing really local solutions for patients and customers both physically and digitally will open the front door of health care.”
In the future, he believes that the local pharmacy will focus on health (prescriptions, counseling, and polypharmacy management), well-being (vaccines, blood pressure, and lipids monitoring) as well as some acute illnesses. He hopes that making the pharmacy an important part of the digital front door will increase preventive health by making it more available at lower costs, especially to people of lower socioeconomic resources.
Walgreen is partnering with Village MD to open co-located doctor–led primary care clinics. They explicitly mention targeting chronic disease patients, but we suspect that, as usual, they have diabesity, heart, lung, and kidney disease in their sights, not autoimmune/inflammatory.
It’s quite easy to see how this model could be helpful for autoimmune patients, e.g., early detection of rheumatoid arthritis and thyroid disease, but we will need to see if their plans even focus on this population.
2. CVS/Aetna – from retail Rx to a broader approach to healthcare
CVS/Aetna connects consumers with the health resources of CVS Health in communities across the country as well as among Aetna’s network of providers. The goal is to remove barriers to high-quality care and build lasting relationships with consumers. They hope to make it easier for them to access the information, resources, and services they need to achieve their best health.
CVS Health footprint includes the following:
CVS Health also serves an estimated 39 million people through traditional, voluntary, and consumer-directed health insurance products and related services, including a rapidly expanding Medicare Advantage offering.
Larry Merlo, President, and CEO of CVS Health reflected that
“As a company, we are 20 months into transforming the business with CVS and Aetna coming together. The pandemic became an opportunity to reprioritize elements of the transformation journey to deliver health services, create new solutions, and make them accessible in nontraditional settings.”
He sees a future where they can play a role in fostering reliable public health information. Given the amount of dis- and misinformation around vaccines, the coming massive COVID vaccine rollouts are an opportunity for CVS as a major cold-chain distributor and vaccine dispenser to play a positive role.
Karen Lynch, EVP CVS Health and President of Aetna commented
“We were continually innovating around new products and services while consumer behavior was changing rapidly as the virus was raging. People want to access healthcare digitally. Delivery of more health care in the home than before means we will continue to see transformational changes in healthcare post-pandemic.”
For autoimmune and autoinflammatory patients, making the corner pharmacy more accessible will only be marginally helpful for some routine care (e.g., vaccinations, regular prescriptions). However, home delivery of prescription and OTC products can be a life-saver for autoimmune patients in voluntary or involuntary isolation.
However, if companies like Walgreens and CVS could figure out a more consumer-friendly way to distribute and administer infusion biologic drugs, that could be a game-changer. Getting access to biologics could be part of putting clinics inside the pharmacy that focus on the needs of autoimmune patients by streamlining some of the more routine and repetitive aspects of their care.
As I reflected on pharmacies becoming the digital front door, I wondered if dental offices, which currently see many consumers twice a year for their regular cleanings, will also try to expand their offerings. Dental practices are already screening patients for oral cancer, sleep apnea, and periodontal disease (which can trigger autoimmune disease and flares). Perhaps they can expand this list to offer thyroid screening, nutrition coaching, and other services that relate to the mouth as a gateway to the rest of the body, including to the immune system.
In addition to the expanding role of the pharmacy in care delivery, there are other new competitors. Some examples follow from women’s, family, and behavioral health. Online clinics are experimenting with novel delivery models, using women’s health needs as the digital front door.
Maven is the world’s largest virtual clinic in women’s and family health. They offer on-demand access to over 1,000 women’s and family healthcare providers. They also connect their clients with dedicated care coordinators who personally help users navigate their benefits.
According to Katherine Ryder, the Founder, and CEO of Maven,
“At Maven we owe better care to the next generation and this starts with a focus on family health.”
She continued,
“one of the silver linings of COVID is that digital health companies with new virtual models to support more holistic and patient-centered care will have a more urgent place in our system today.” In addition, “we are integrating care for parents with care for kids to support the well-being of the entire family.”
Women of childbearing age are at higher risk of autoimmune, autoinflammatory and conditions like chronic fatigue syndrome than any other demographic. With Maven’s focus on family health, they could easily offer screening for autoimmune disorders, including genomic testing (which they are likely doing already for fertility and family planning purposes) to identify those who are at higher risk.
This could be integrated with their intergenerational approach, looking to detect or even prevent chronic immuno-inflammatory conditions in their patients’ children. They could help connect autoimmune patients with specialists or even coach them in lifestyle modification approaches that may reduce their chances of developing disease or at least get them earlier diagnosis and treatment.
kindbody is expanding access to fertility and reproductive health with virtual or in-clinic care for fertility, gynecology, and wellness. With transparent pricing, their website includes pricing information for services such as IVF, egg freezing, and embryo banking, as well as nutrition counseling. Care teams can include an ob-gyn, endocrinologist, physician assistant, and a variety of counselors and coaches.
According to Gina Bartasi, the Founder and CEO of kindbody-
“kindbody is on a mission to increase access to fertility and family-building care for all. 50% of our corporate team identifies as non-caucasian, 45% of our patients are women of color and 15% are GBTQ+ so when we think about creating change, we are really being mindful of today’s social inequity.”
For autoimmune patients, many of whom are women of color with low incomes (a group that faces slower diagnosis and less aggressive care), a logical extension of kindbody’s current offerings could include autoimmune screening as part of genetic testing used for family planning as well as routine thyroid screening for autoimmune thyroiditis, the most common autoimmune diseases among women.
Furthermore, kindbody could help connect autoimmune patients with specialists or even coach them in lifestyle modification approaches that may reduce flares or their chances of developing a disease or at least get them earlier diagnosis and treatment.
brightline is reinventing behavioral health care for children, teens, and their families.They deliver integrated care through innovative technology, virtual behavioral health services, and a collaborative care team focused on supporting children across developmental stages and their families.
Given the ongoing explosion of mental and behavioral health issues among children, teens, and young adults, especially under the stress of COVID-19 lockdowns, the current environment is ripe for a solution like brightline.
According to Naomi Allen, CEO and Co-Founder of brightline, we are
“providing uncommon support to the most common family challenges in behavioral health”
As shown below, brightline offers the broadest multidisciplinary care teams of any of the companies (not just the female/family offerings) profiled in these posts. This represents more silo-busting coordination of specialists than any of the other platforms. As an advocate for autoimmune patients, I am happy to see this innovative approach being used. I’ve provided screenshots to show this competitive advantage.
brightline provides access to a wide variety of providers, including:
Amongst other services, they offer tailored content, telehealth visits, treatment plan tracking, and digital exercises at home.
Particularly noteworthy is their approach to prevention, which includes a yearly pediatric well visit as shown below.
Brightline is an example of diverse multidisciplinary care teams being scaled through digital technology to help children with a wide variety of therapy programs. Better care coordination and specialist collaboration is needed by autoimmune patients, too. What’s more, autoimmune patients, an increasing number of them children, almost always have comorbid mental health issues, primarily depression and anxiety.
It would be a logical extension of the Brightline approach to reach out to their mood disorder patients to see how many in their families suffer from chronic diseases, especially autoimmune, maybe even undiagnosed immuno-inflammatory disorders.
Taking this even further, a platform like this could work for chronic GI conditions with immunological aspects such as the IBDs (inflammatory bowel diseases: Crohn’s and ulcerative colitis). Given what we now know about the gut-brain axis, GI diseases almost always involve a big mental health component.
Specifically, brightline could offer IBD patients access to care teams that include gastroenterologists as well as dieticians, health coaches, and psychologists that could help them better manage their daily lives between regular appointments. Such an approach could help IBD patients avoid flares and complications requiring costly hospitalizations or emergency visits.
In addition, applying brightline’s prevention approach to their population of families could allow earlier identification of IBD, especially in children, when early lifestyle modifications (diet triggers, food sensitivities) might prevent the disease altogether.
The HLTH VRTL conference was an excellent opportunity to capture a glimpse of some of the changes brought about by the COVID-19 pandemic. The sudden, pandemic-triggered the following changes:
1. An increase in the use of telemedicine and remote monitoring,
2. A shift in payment models to VBC that is accelerating competition for the digital health front door (See above “Competition for the Digital Front Door”).
3. A spurring of a variety of new care delivery models. (See above “New delivery models focus on women’s, family, and behavioral health”).
4. Increasing competition for attracting patients through the digital front door that includes an expanded role of pharmacies, as well as new, digitally enabled, integrated approaches to women’s and family health.
Throughout HLTH VRTL there was almost no mention of autoimmune or other chronic immuno-inflammatory diseases, making it harder to see how these new players might help patients with these conditions.
This omission is telling in terms of where healthcare managers are focusing their efforts. While mental health is now receiving more (well-deserved) attention, autoimmune, autoinflammatory, and conditions like chronic fatigue and post-viral syndromes, easily as costly and as big a cause of human suffering as cancer, are still invisible to most payers and many providers.
Maybe the emergence of post-COVID syndromes (aka long covid) will finally prompt payer and provider interest in chronic immuno-inflammatory disorders in the same way the pandemic & lockdowns have speeded previously slow progress in telehealth and work from home.
There is no one-size-fits-all approach for autoimmune patients and much experimentation is needed, especially since so little has been done outside a handful of small companies that are mostly focused on individual autoimmune diseases.
I hope next year’s HLTH conference will offer more tangible examples of how large and small healthcare companies are using telemedicine, remote patient monitoring, new delivery care models, including VBC reimbursement to better serve the individual daily needs of chronic autoimmune patients.
Elevating and improving the role of primary care through digitally-enabled platforms and salaried physicians in both established delivery systems and new care models could also benefit immuno-inflammatory disease patients. However, this will only happen if payers and providers focus on this huge unmet need/business opportunity.
We still wonder where immune disease specialists: dermatology, rheumatology, gastroenterology, immunology, endocrinology, fit into these models. Are specialists going to become members of coordinated care teams? Or will they be in satellite practices coordinated through digital platforms that help chronically ill patients get the full spectrum of care they need? How will these new models and digital platforms tackle the complexities of chronic autoimmune and autoinflammatory disease diagnosis and treatment?
Such questions would be good ones for HLTH and its participants to focus on for 2021.
This article examines the future of healthcare in a post-COVID-19 world as gleaned from the HLTH VRTL 2020 online mega-conference. It also explores the impact of the future state on the care of chronic inflammatory diseases, my area of focus. As I engaged in virtual sessions and networking, I viewed them through my lenses as a financial analyst, business consultant, and patient.
In keeping with my mission at Your Autoimmunity Connection, I constantly kept one question in mind. How could these post-COVID changes help patients with autoimmune and autoinflammatory conditions?
I love going to conferences, from the anticipation of adventure with my well-worn suitcase and beloved travel clothes. Plus the excitement of meeting new people in the most unlikely locations: bathrooms, hallways, and elevators. For me, conferences have been intermittent opportunities to take the pulse of digital health.
In the past, HLTH has been one of the best such adventures. In 2019, I shared a room with Mette Dyhrberg, founder of Mymee, a great way to collaborate on our joint missions to improve research, diagnosis, and care for autoimmune patients.
This year, 2020, the Year of the COVID-19 pandemic, is different. With safe travel options limited, we are all adjusting to virtual conferences.
I am happy to report that the HLTH VRTL platform execution was superb. During an entire week of online presentations and one-on-one virtual meetings, the platform never crashed. In fact, that dreaded circular buffering icon never once appeared. Kudos to the HLTH VRTL tech team for creating a seamless virtual conference experience.
First impressions are key. HLTH did a great job setting the stage. They started with an inspirational video and followed with an informative statistics video.
Among the myriad of tracks, I found the daily recaps with Andy Slavitt, Leona Wen, and John Brownstein to be useful and informative. These helped me to quickly identify the healthcare delivery trends that I think might be important to chronic autoimmune and autoinflammatory patients.
Below are highlights of selected sessions, framed by my analysis and commentary on how disruptive post-COVID drivers of change might help create a new normal that will better meet the current and future needs of autoimmune patients.
In the “Future of Telehealth,” section of the HLTH Counterpoint Series, Tina Reed, Executive Editor of Fierce Healthcare, moderated contrasting perspectives on the future of telehealth from Roy Schoenberg, President, and CEO of Amwell (NYSE: AMWL), and Mario Schlosser, CEO of Oscar Health.
Amwell is a leading telehealth platform provider in the United States and globally. It connects and enables stakeholders to deliver greater access to more affordable, higher quality care. These include:
With over a decade of experience, Amwell powers telehealth solutions for over 2,000 hospitals and 55 health plan partners with over 36,000 employers, covering over 80 million lives.
Roy Schoenberg, CEO of Amwell, said,
“The coronavirus has shown people that delivering healthcare with technology has a role to play. We have a strong voice for the payer and provider, maybe we are beginning to see the arrival of the patient voice…If we can create a gratifying experience for the people that we serve over the long term that is a winning strategy.”
He continued,
“There is an important question as to whether these technologies are part of the delivery or the payer side of care.”
He sees a future where group practices are enabled by technology to be more easily accessible to patients while providing great customer service and communication. Rather than viewing telehealth as just another “tool”, he believes that a “home run” would be when:
”Telehealth is a care setting in which traditional medicine is delivered and the home front will be the most coveted care setting.”
Chronic disease patients, especially autoimmune and autoinflammatory disorders patients, need ongoing support between regularly scheduled appointments. The expanding use of telehealth may benefit them.
Telehealth can enable more frequent, convenient, yet less costly encounters from patients’ homes. This is even more true if telehealth is not just replacing PCP encounters but augmenting them with coaching and other staff. Coordinating with specialists is another important feature for chronic and autoimmune disease patients, but that doesn’t seem to be as far advanced.
Oscar Health is a hybrid insurance company, telemedicine platform, and primary care provider, based in the Pacific Northwest. Founded in 2012, Oscar Health was the first direct-to-consumer (DTC) health insurer. It facilitates member engagement with their own full-stack technology platform that handles both the insurance side and the care delivery side of the business. This includes:
Oscar is one of many companies building variations on care teams to improve coordination, delivery, and customer service while controlling costs. These teams, which Oscar calls concierge care guides, can help patients do the following:
This approach: digitally supported personalized care teams led by nurses, coordinated by guides (aka coaches), and physicians. The personalized care teams provide a range of care, including chronic disease plans, which is similar to ideas we’ve proposed from 2014 on to help CID patients navigate their complex ongoing care.
Mario Schlosser, CEO of Oscar Health, told HLTH that the COVID boost to telehealth is a
“huge opportunity to bend the cost curve and increase the number of touchpoints (visits) and therefore reduce the variation in care.”
For autoimmune and autoinflammatory disorders patients, more telehealth visits and remote monitoring of symptoms, medications, etc. between appointments could help them reduce flares, better manage side effects, and avoid costly emergency care and hospitalizations.
Schlosser sees a future where there will be more remotely enabled physician practices that take on the financial risk themselves so that
“the number of physician visits go up, but the price goes down.”
In conclusion, telemedicine and remote patient monitoring are enabling technologies, much needed. However, they have not yet directly focused on autoimmune or autoinflammatory disease care.
Using telehealth to expand access, speed, and the number of encounters, along with the expanded use of care-based team models that include specialists, could potentially benefit autoimmune patients.
Likewise, remote patient monitoring can enable better chronic autoimmune disease care. However, this will only occur if payers, providers, and platform companies finally focus on this invisible opportunity, as costly and complex as cancer.
Value-based care (VBC) offers a new financial foundation for healthcare delivery business model experiments. From the perspective of autoimmune patients, I wonder if the VBC payment models better support the long-term, multiple-modality care coordination that such patients need, but have generally not received from FFS delivery models?
Bryony Winn did a great job setting the stage, asking why this is a good time to discuss “A Push Into Value-Based Care”, as she asserted that:
From my perspective, FFS has not been a good model for chronic disease management, let alone, chronic antiinflammatory, and autoimmune diseases. The key question is, will VBC payment models support providers and practices to provide better care for lifelong chronic inflammatory patients?
The Massachusetts General Physicians Organization (MGPO) is the largest multi-specialty medical group in New England and one of the largest in the U.S.
Dr. Timothy Ferris- CEO of Mass General Physician Organization, said,
“I do not see [hospital-led ACOs vs independent physician practice-led ACOs]as an either-or? [Hospital-led ACOs] have capital that can be redeployed in ways that generate benefits for the system and patients…The key thing is investing in the infrastructure and services that the FFS model does not pay for.”
These include:
How can big ACOs compete with new, inexpensive retail FFS offerings? For example, DTC apps such as HIMS, HERS, Keeps, etc. offer one-stop, doc-in-a-box shopping for popular prescription drugs. Other competitors include big point-of-care retailers, like CVS and Walgreens, for acute care, vaccinations, prescriptions, etc.
Ferris continued,
“I think that integrated delivery systems of the future will have to find a model to deliver low-end services.” (flu shots, etc.) as cheaply as their new competitors. “But most of our spend is not on low-value care, but rather on folks who are very sick.”
In part because many very sick patients present with multiple comorbidities, any provider’s ability to reduce the spending on these sick folks is limited.
“We can show that large integrated delivery systems were able to reduce overall system costs by 2%”.
Dedicated care managers (similar to those tracking hypertension patients) could help autoimmune patients with treatment support needs between regular appointments. They could also help foster more proactive flare-prevention strategies.
Autoimmune and autoinflammatory conditions are costly to manage and not just because of specialty medications. However, avoiding flares and thus even more expensive episodes of emergency care and hospitalization strike me as low-hanging fruit, high-return investments for big hospital systems.
Yet this unmet need is an opportunity that seems generally to have been overlooked. Maybe the emergence of post-COVID syndromes, which look very much like autoimmune reactions, will force big provider systems to come to grips with the unseen epidemic of immunological and inflammatory diseases.
Aledade is a platform company that partners with primary care physicians to help them build and lead their own Accountable Care Organizations (ACOs).
Farzad Mostashari, the co-founder and CEO of Aledade, told us that 6 years ago they bet that independent PCP ACOs would win over hospital-led ACOs. The independents were not burdened with the large financial overhead of hospital systems. Therefore, Aledade saw an opportunity to
“Go with those with the most to gain and the least to lose from VBC.”
As of 2020, Aledade serves 550 practices and 7000 clinicians with $10 billion under management.
“It is working and it’s growing.”
Aledade provides regulatory expertise, technology, data analytics, business transformation services, and upfront capital. In addition to all the other elements, independent practitioners need to succeed in value-based care.
Patients are not seeing reduced care. Mostashari said we can offer “more screening, more immunizations, better blood pressure control.” Patients are getting primary care that is “more accessible, more informed, and more engaged.”
Overall, they claim an 8-13% reduction in the total cost of care. Savings vary by state.
Providing affordable, easy to integrate, off-the-shelf IT infrastructure and other business process support tools as well as data management for primary care docs could enable them to better compete with large hospital systems. This might also enable them to offer more timely, accessible care to chronic disease patients, including autoimmune patients.
This leaves open the question of how specialists, much utilized by autoimmune and chronic inflammatory patients, fit in. Specialist practices have thrived under supply-restricted, high-demand FFS models. And so far have not been eager to participate in digitally-enabled care team practices.
Once more, maybe the pandemic disruption to cash cows like colonoscopy will accelerate the previously sluggish migration of specialists to VBC models.
Telemedicine and remote patient monitoring are two necessary but not sufficient enabling technologies for better autoimmune care delivery. Making care more accessible from patients’ homes through telemedicine, apps and the expanded use of care-based team models could potentially benefit those with chronic immune conditions, who need more frequent touchpoints on their care journeys.
The changing reimbursement landscape, from fragmented, uncoordinated FFS to patient-centered (or at least capitation or episode-of-care coverage) VBC may also better financially support care delivery for autoimmune patients. Especially those patients on specialty meds who need monitoring, management, and support between regular physician and specialist visits.
Such care should also include non-pharmacological modes like physical therapy, exercise coaching, diet management, sleep, and mental health support. Some of these pieces are being incorporated into some of the new care delivery models. However, the chronic disease focus has been on cancer, diabetes, and cardiopulmonary disease, not inflammatory, immunological, autoimmune or autoinflammatory conditions.
The conference focused on bringing virtual primary care into the home or at least to the smartphone. However, I have unanswered questions concerning the role of specialists in these new models. How will team-based care coordination integrate the multiple specialists (e.g. rheumatologist, gastroenterologist, dermatologist, neurologist) many autoimmune patients need to guide chronic care?
I turned the corner and there it was. The Death Star, as locals call it, because it’s star-shaped, imposing, and has a helipad on the roof. Also known as the Queen Elizabeth University Hospital in Glasgow—a state-of-the-art, 14-floor hospital completely interlinked, part of the National Health Service in Scotland—it was the site of the Non-technical Skills for Surgeons (NOTSS) Master Course I was invited to join.
In my exploration of what makes a good surgical team, I came across “Teamwork Assessment Tools in Modern Surgical Practice.” That article inspired me to write Can Surgery Teamwork Save Your Life?, describing one of the best assessments, Non-technical Skills for Surgeons (NOTSS).
Any excuse to travel is all right with me. The Royal College of Surgeons-Edinburgh offered a NOTSS Master course on a day I was available. So I headed to Glasgow for a few days of Scottish music, single malt scotch, and museums before the course.
NOTSS is a program to train surgical residents (and more senior physicians) in non-technical skills. They are specifically referring to the behavioral elements of optimal surgical performance.
UK surgeons who are accepted into the Royal College are called Mr, Miss, Ms, or Mrs rather than doctor. Mr. Simon Paterson-Brown and Mr. Simon Gibson kicked off the day with the usual medical statistics about using checklists in the operating room, or theatre, as it’s known in the UK. Routine use of checklists halves surgical mortality, from 1.5% to 0.8%
Using a checklist might have prevented Sheila Hynes death in March 2017, after her new heart valve was put in upside down. The two Simons asked us, “What goes wrong in your theatre?” Reasons for errors include the following:
Human factors, leadership, and communication, all included in non-technical skills, are the top three contributors to Sentinel Events. These are unexpected events in a healthcare setting that kill or harm patients and that are unrelated to the patients’ illness.
As I learned, NOTSS is not about:
And there is no single vaccination for immunity.
NOTSS is about normal people, places, organizations, and systems. It’s about recognizing complexity and optimizing performance.
Other stories by this author: A Fatal Medical Error: Lack of Care or Lack of Caring?
High on the list of necessary skills for effective surgeons is situational awareness. This is the state of being aware of what’s around you even as you focus on the task of surgery.
Check out this video to test your own situational awareness.
Here are some ways to enhance situational awareness:
I’M SAFE is the mnemonic for a self-check list at the beginning of the day and when starting new or major procedures. Are you having any negative effects from the following?
While observing surgeons, use CUSS for graded assertiveness:
In 1977, KLM Flight 4805 and Pan Am Flight 1736 collided on the runway in Tenerife. This was the deadliest airplane accident in history at that time, killing 583 people.
The pilot was Captain Veldhuyzen van Zanten, KLM’s chief of flight training and one of their most senior pilots. He took off without clearance, smashing into the other 747 on the runway.
In 2009, Captain Chesley “Sully” Sullender landed a crippled airplane on the Hudson River, with no loss of life. In the former, other crew members were reluctant to question the captain. They died. In the latter, the team concentrated on doing the right thing at the right time. They lived.
According to TeamSTEPPS, they
Good quality operating room leadership leads to decreased errors, reduced costs, improved safety, and increased compliance with standard operating procedures (SOPs).
Despite that, 47% of surgeons believe the decisions of the “leader” should not be questioned. So did the crew members of Captain van Zanten. And, contrast that with the present time where only 7% of pilots have that belief, a smaller percentage after changes were implemented following the Tenerife crash.
One solution is to send your surgeons abroad for NOTSS training. Another is for them to take the course at the annual American College of Surgeons meeting. This is where there is often a workshop on this topic.
The book, Enhancing Surgical Performance: A Primer in Non-technical Skills,* offers a detailed road map for “structuring observation, rating, and feedback of surgeons’ behaviors in the operating theatre.”
Anyone involved in surgery—surgeons, nurses, residents, students—will learn what to look for and how to perform to increase staff well-being and decrease patients’ deaths and errors in the surgical suite.
I use this assessment with my surgeon coaching clients as I observe them in the operating room with their teams. The experience changes how they approach the surgery process. Becoming adept at non-technical skills literally changes lives for the better—patients’ lives.
As the great sage, Yoda said,
“Do. Or do not. There is no try.”
1.NOTSS Website: https://www.notss.org/
2. Industrial Psychology Research Centre, University of Aberdeen (all handbooks)
3. Intercollegiate Surgical Curriculum Project (NOTSS handbook)
*Indicate an affiliate link. We may make a small commission if you purchase this book using this link. It will not affect your price, but it does help us do our work.
Published 6/3/17. Reviewed and updated 12/3/20.
Mr. Humphrey was a relatively healthy guy, but he always knew that he had a family history that put him at risk of developing pancreatitis. So when he developed persistent symptoms—abdominal pain, fever, and nausea, he finally visited his doctor. She diagnosed him with pancreatic inflammation and immediately referred him to the University of Alabama-Birmingham’s (UAB) Pancreatobiliary Disease Center.
There, he was seen not by a single specialist, but by a multidisciplinary team that included pathologists, surgical and radiation oncologists, and others—including me, an interventional radiologist. Mr. Humphrey was particularly fortunate to be able to receive advice, counsel and a treatment plan that benefited from a broad range of medical perspectives, providing him the highest quality of care and peace of mind. If we could offer care like this to all our patients, imagine what we could do for them.
Every patient is unique and often care cannot and should not depend on the individual skills of any single specialist. While many medical specialists have the expertise to treat these conditions, if a practitioner works alone, he or she is often working within a narrow professional silo.
That could blind them to holes in treatment, means of treating unaddressed symptoms, and alternative approaches that can actually be life-saving or life-restoring. Pancreatobiliary conditions are particularly complex and notoriously difficult to treat. They may seem innocuous at first, but without optimal management, they can be fatal.
Until 2018, our facility had a patchwork of working relationships among multiple specialties. However, we knew there was room for meaningful improvement. That’s why we established our multidisciplinary model for collaborative, patient-centered care.
Our model brings together 13 specialty providers who meet every Wednesday morning. Instead of a haphazard system based on quick “hallway consults” among physicians, our team benefits from formal scheduled presentations of approximately a dozen cases each week. This enables us to have a healthy, holistic discussion of each patient’s needs. It also allows us to better coordinate each patient’s ongoing care.
In Mr. Humphrey’s case, this allowed specialists from surgery, interventional radiology, diagnostic radiology, and endoscopy to review his images and clinical history in detail. We were able to place his clinical course within our multi-disciplinary, algorithmic approach to pancreatitis and then tailor it to his specific needs.
Interventional radiology was able to provide an image-guided drainage of his infection. After hospital discharge, he was seen in the surgery clinic with notes about output and clinical symptoms sent to the interventional radiology clinic. This allowed for easy coordination of care when manipulation of the drain was required.
Ultimately, as a team, we were able to manage this difficult illness in a relatively short period of time without invasive surgery.
Significantly, we have also developed cross-specialty protocols for various conditions, from cancers to cysts, to outline where every team member fits within the care plan. These established roles ensure we are all on the same page and the process itself builds trust and enhances the value of each specialty’s approach.
Having support from our hospital leadership has been critical to our success. Their backing has helped to nurture the model into a large-scale effort. The goals are to:
But beyond these improvements, our team has been able to build capabilities and relationships among physicians to grow personally and professionally. We believe we are moving the field forward.
Related content:
Why Collaboration is so Important in Autoimmune Disease
Differences between Peer Specialists, Alumni Coordinators, and Sponsors
Our model is just one example of how collaboration on this scale can work wonders for patient care. But there are many medical facilities that have not had the motivation or capability to do so. I can speak from my personal experience that this goal can be accomplished with a few steps.
It starts with honestly acknowledging the gaps at your institution. Ask yourselves: What is missing in your procedures and outcomes that could benefit from this kind of collaboration? Where can specific improvements be made in patient care? And how do we do it?
Hold open, face-to-face conversations with other specialists to begin forming partnerships, and most importantly, trust. Taking the time to meet with each other and show that you value others’ opinions will help to form a professional bond between providers. It also fosters a team mentality.
Finally, when you’ve accomplished those goals, getting buy-in from top leadership and from the relevant players in key hospital services will build momentum for change. These relationships are key to making sure you have the resources and personnel to generate a meaningful transformation.
Related Content: What Do Patients Think About Team-Based Care?
Above all, you will be able to create a new mindset among your colleagues: Instead of asking “What can I do for this patient?” we now ask “What is really best for this patient?”
If your nursing units don’t function well together, it not only makes work frustrating for your nurses, it can literally affect patient outcomes for the worst.
Cultivating a strong nursing team takes a lot of time and effort. However, it pays dividends down the line.
Rome wasn’t built in a day and neither were good nursing relationships. It takes time to figure out the personalities of all your teammates and to establish rapport.
Trying to artificially rush things can make your working relationships incredibly awkward. It can even backfire altogether. (HINT: there’s a reason people hate icebreaker games so much).
Start small, such as grabbing lunch or coffee with a couple of coworkers. Then, build the relationships from there.
Whether it’s a marriage or a nursing unit, good communication is the foundation of any solid and successful team. Whether it’s written or verbal, always strive to be clear and understandable as you communicate with your coworkers. Encourage them to reach out for clarification if needed. Be sure to demonstrate your willingness to answer legitimate questions.
It can be tricky to hit the balance between these two important attributes. On one hand, you want your nurses to feel comfortable discussing important topics, such as unfair workplace treatment or difficult patients. This will help you to craft solutions together.
On the other hand, however, you don’t want the culture to be so open that gossip quickly spreads. This will undermine trust and make people feel like they can’t say anything if they don’t want the entire hospital to know.
If you’re a nurse manager, your nurses will look to you to set the tone for the unit. So do your best to be candid with your staff (when appropriate). And don’t perpetuate gossip no matter how tempting it might be.
If it’s everyone’s responsibility, then it’s really no one’s. Either the task won’t get done because everyone thinks someone else is doing it or the same few overachievers will end up picking up the slack, eventually burning out from all the extra work and maybe even hanging up their scrubs for good as a result.
To avoid this scenario, make sure that roles are clearly defined and that each person knows what their job is and how to do it. Again, it all goes back to clear communication: Broadcasting expectations for roles keeps nurses from having to guess what their job is or what their supervisors want.
Dealing with conflicts can be messy, dramatic and emotionally exhausting. Sometimes, it feels easier to just sweep things under the rug rather than address the dispute head-on.
But ignoring conflicts will just set you up for even bigger arguments in the future. And lead to festering tensions that can impair the quality of nurses’ work. If you have an issue with a coworker, try to address it with them directly rather than involving a supervisor, at least at first.
If you are the supervisor, encourage your employees to stand up for themselves and talk things out in a measured, adult way. However, do let them know you’re willing to act as a third-party mediator if they can’t resolve the conflict on their own.
Whether it’s large or small, every single nurse is going to make a mistake at some point in their career. Rather than punishing or shaming them for their slip-up, seek to understand why it happened. More importantly, seek to find ways that your team can avoid repeating the error in the future.
Practice empathy and put yourself in their nursing shoes. How many errors have you made during your nursing career? Every mistake is a potential teachable moment. Remember, nurses won’t improve unless they have someone to gently point out where they went wrong and show them the right way to do things.
Oftentimes in teams, people clamber to take credit for a successful project. Or they point fingers at everyone else when something goes wrong. Rarely, however, is only one person responsible for either the credit or blame when it comes to working in teams. Of course, the same is true when the team is a nursing unit.
Show your team this in action by sharing in both their triumphs and failures. Don’t throw anyone under the bus when something goes wrong. After all, they are probably looking to you to see how they should act.
Every nurse, yourself included, cannot deliver 100 percent perfection 100 percent of the time. Mistakes will be made. Life gets in the way and people can’t stick to agreements they previously made.
Encourage your team to be upfront when this happens to them. The sooner people know what’s happening, the sooner they can make a contingency plan.
Yes, it’s uncomfortable when you can’t come through as you promised. But it happens to everyone and delaying the inevitable will only make things worse.
People know when they’re being complimented for something that wasn’t actually a big deal. And they definitely know when they’re not being recognized for a hard job well done.
Recognize your nurses when they truly go above and beyond, whether that’s just a heartfelt “thank you” or handing out fun awards to people in your unit. Keep in mind that this recognition may look different for each person. Some people love being applauded in front of the whole team, while others prefer to receive a nice card with little fanfare.
Building a strong nursing team takes a lot of work, but it’s far from impossible. Follow these nine tips to make sure your nursing unit is working together to reach its full potential.
On Friday, June 30, 2017, a gunman opened fire on the 16th floor at Bronx-Lebanon Hospital Center in New York City. He killed one physician and wounded five other physicians before killing himself. In the chaotic moments that followed, two physicians from North American Partners in Anesthesia (NAPA) joined their colleagues and hospital staff to provide care for the wounded and help manage the unfolding tragedy. NAPA’s leadership team, from its base on Long Island, New York, provided support to their colleagues and friends on site and to the hospital’s leadership. How both the NAPA team and Bronx-Lebanon team pulled together—saving lives, facing danger, and providing support to all involved in the shooting—is a case study in leadership.
Dr. Dave Livingstone, NAPA site chief at Bronx-Lebanon, was writing orders on patients in the post-anesthesia care unit when he heard the first code silver over the PA system. Several additional overhead codes immediately followed, then a call for all available personnel, stat.
In those initial moments, it was unclear what was unfolding, how many victims were in need, and just what dangers might be encountered. Dr. Livingstone knew he needed to respond. He recalled, “No one knew for sure what was happening, but from the moment we all felt threatened, we all pulled together.”
He grabbed the anesthesia code bag and a colleague, Dr. Eun Jung Park, and together they ran toward the location. The two entered the elevator and pushed the button to go up. Instead, the elevator took them directly to the ground floor. The doors opened and SWAT officers in full gear began yelling commands as they pointed automatic rifles inches from their faces. Drs. Livingstone and Park were escorted at gunpoint out of the elevator and out of the hospital. The SWAT officers were systematically clearing the hospital. Everyone was considered a suspect. Dr. Livingstone knew the SWAT response protocol from the training he received during an active shooter course he attended with colleagues two years prior.
“I knew that if we did not comply with all orders, we would be considered hostile and could be shot.” He continued, “Staying calm and following their direction was probably one of the most difficult parts because everyone was scared.”
Once outside, Drs. Livingstone and Park made their way to the side of the hospital, identified themselves as anesthesiologists, and were ultimately escorted—still at gunpoint—into the Emergency Department (ED). That was the first moment they encountered the victims of the shooting. Doctors, nurses, and other staff members were carrying victims down the stairwell and into the ED. Once Dr. Livingstone arrived, he met Dr. Ajay Shah, the assistant vice chair of surgery, and together they started the triage process.
The first two victims were gravely injured. One had suffered a gunshot wound to the abdomen, resulting in severe trauma to the liver; the other had suffered a gunshot wound to the head. Both were intubated immediately. Drs. Livingstone and Shah rushed the victim with the abdominal wound to the OR. Three more wounded victims were also in need of emergency surgery and were urgently transported to operating rooms. A sixth victim had died. The surgical, anesthesia, and nursing teams frantically prepared five operating rooms for five trauma surgeries simultaneously.
“From the moment we learned that these were our colleagues and one had died, we wanted to go above and beyond to take care of our own. Once we found out we were under attack—that doctors were under attack—there were no egos. It was game on.”
Dr. Dale Anderson, NAPA’s managing partner, was in his car somewhere north of the Throgs Neck Bridge when he received a text message from Sheryl Blumberg, NAPA senior director of human resources, saying that there was a shooter at Bronx-Lebanon. “I knew that Dave and his team were in trouble and needed help, so I went,” Dr. Anderson said.
After arriving at the hospital, Dr. Anderson encountered a barricade of law enforcement. “When I explained who I was and what I wanted to do, they really worked to get me inside as fast as they could. Hundreds of police officers in full assault gear were positioned at the hospital entrance all the way up to and inside the OR.”
Upon arriving in the OR, Dr. Anderson located Dr. Livingstone, gave him a hug, changed into scrubs, got a quick report about what was happening in the five rooms, and asked where he was needed the most. Dr. Livingstone directed him to the patient with the liver trauma.
“What happened at Bronx-Lebanon was beyond what any institution plans for unless it’s a MASH unit in a forward military zone. All of us have had gunshot wounds at our hospitals. It’s very frightening, but that’s just one. Multiply that by five, and the scene goes from terrible to simply surreal,” said Dr. Anderson. “To this day, it’s hard for me to wrap my arms around what I saw. I’ll never forget it.”
Dr. Sheldon Newman, NAPA regional director, recalls receiving a text message from Dr. Livingstone before anyone saw it on the news. The message was simple: “Shooter at Bronx-Lebanon, all our people are okay.” Word spread quickly throughout the NAPA office. The NAPA leadership team was quickly mobilized. Dr. Newman worked with Barbara Cerrone, NAPA senior director of marketing, to develop a brief message to send to the entire organization.
Dr. Newman explained, “NAPA is a very large organization. It also happens to be a very close-knit organization, and our people were genuinely concerned for Dave and all our staff at Bronx-Lebanon.”
In all, 16 NAPA staff members were working at the hospital at the time of the shooting. Dr. Newman said, “Our immediate response was concern for the safety of our people there, these poor victims, and everyone at Bronx-Lebanon during this horrific tragedy. How could we support them acutely, emotionally, for that evening and over the ensuing hours and days? It was the mission of the entire leadership that our only concern was for patient safety and the emotional stability of the staff.”
Dr. Livingstone commented on the support of NAPA leadership, “The team was comforted by Dr. Anderson’s presence. We felt the entire NAPA organization was behind us.” In fact, Dr. Livingstone received dozens of supportive messages from NAPA providers across the enterprise.
As the hospital’s provider of anesthesia services, NAPA has a relationship with Bronx-Lebanon. NAPA identified the importance of communicating a consistent message of support to the Bronx-Lebanon clinical and administrative leadership. Tom Delaney, senior vice president of client services, commented, “I think it helped to convey that we were all rowing in the same direction at a very difficult time. That’s the kind of relationship we’ve been able to establish at this institution.”
Dr. Anderson noted, “The Bronx-Lebanon chief medical officer and leadership didn’t just have the OR to worry about, but also the entire institution. What we did was help them understand how to best manage the perioperative space. That’s where we live. Over the next four to five days, we helped ensure the staff had appropriate focus and that the patients were safe. They were appreciative of our insight.”
NAPA and Bronx-Lebanon leadership collaborated closely to ensure there was support for the perioperative team. Elective surgery cases were temporarily suspended to allow people to reflect and process what had happened. The NAPA and Bronx-Lebanon Human Resources Departments partnered to provide immediate and ongoing crisis management and counseling to the perioperative team. Staff was encouraged to speak about what had happened and were given the option of private counseling sessions on an as-needed basis.
Embroiled in the pandemonium, Dr. Livingstone credited the success of the response to team cohesion and working together toward a single goal. “I have read all kinds of management books and taken business courses, but living through this experience has really driven it home for me. When something like this happens, teamwork becomes a matter of life and death.”
Related Content: Mental Health Matters for Gun Violence Survivors
Dr. Livingstone: “I learned the value of a well-coordinated team response. We talk about teams and how they function, but in the condition of extreme stress—when everything you do counts and every minute matters—it’s the team’s cohesion and the ability to work together toward a single goal. I have read all kinds of management books and taken business courses. We talk about it, but living through this experience has really cemented this, driven this home for me.”
Dr. Newman: “What I saw was the immediate and united response from all leadership. It never wavered in unanimity and commitment to supporting our staff and the patients and people at Bronx-Lebanon at all cost.”
NAPA plans to incorporate the lessons learned from this tragic situation into its leadership training programs. Barbara Cerrone, NAPA senior director of marketing, said, “We’re living in an age where, sadly, these acts are increasingly common, and we have a responsibility to educate our teams on how best to handle themselves and the situation, should it arise.”
The NAPA and Bronx-Lebanon leadership took responsibility to ensure immediate and ongoing crisis management in the perioperative team. Their actions exemplify the principles of Extreme Ownership, leadership lessons based on U.S. Navy SEAL training. The principles, embraced by The Doctors Company, have helped us build high-performance teams within our own organization.
There are approximately 1.65 million Intensive Care Unit patients who are mechanically ventilated in the U.S. each year. In addition, mechanically ventilated patients are found in long-term acute care (LTAC) facilities, extended care and skilled nursing facilities, and in some home care settings. As a practicing pediatric cardiologist, I have witnessed the harmful consequences for both the patient and caregiver when the closed circuit of mechanical ventilation is broken in order to perform procedures, such as deep suctioning, that require the circuit to be opened.
Although there are systems on the market that allow for closed suctioning of patients, it is recognized that it is often necessary to disconnect the patient—that is, break the circuit—to achieve meaningful, effective suctioning assisted by manual Ambu bagging. Moreover, most respiratory therapists, if given the choice, would Ambu bag the patient while suctioning as this will result in a more effective pulmonary toilet. It also may be necessary, at times, to break the circuit when medication needs to be dispensed, pulmonary function tests need to be performed, and, in some cases, when bronchoscopic procedures are required.
As noted above, in order to accomplish deep and effective suctioning, it is often necessary to disassemble part of the respiratory support system either by removing the ventilator manifold or by opening a port and inserting a small diameter suction tube down the tracheal tube and into the patient’s trachea and lungs. The fluid is then suctioned from the patient and the suction catheter is removed and the respiratory support system is reassembled.
Due to the high air pressure within the circuit, secretions that have built up in the system may end up being catapulted into the air upon opening. This loss of pressure and hence loss of PEEP (positive end expiratory pressure), often results in alveolar collapse, hypoxemia, and all the complications related to it. This also exposes the patient to the possibility of ventilator-acquired pneumonia and the caregiver to contamination.
Adults with ARDS (acute respiratory distress syndrome), immunocompromised patients, and premature babies are particularly vulnerable to these threats. For example, I had a personal experience with a baby born with pulmonary hypertension of the newborn. These babies are extremely sensitive to airway pressure changes and to changes in oxygenation. In the case of this delicate newborn, suctioning of the airways was extremely critical. Therefore, the circuit needed to be broken at one point during treatment to achieve deep, effective suctioning. This resulted in profound desaturation that placed the life of the baby at risk, and significantly prolonged his hospital stay due to complications from that event.
These unnecessary complications often lead to extended stays in the hospital, increased morbidity and mortality, and unnecessary treatment of the patient. It should not be surprising that these avoidable adverse outcomes contribute to the skyrocketing healthcare costs that we are experiencing in our country.
My colleague Neil Winthrop, a registered respiratory therapist, and I set out to develop a way to build a device that could protect mechanically ventilated patients from the risks associated with breaking the closed circuit. We designed the BayWin Valve in collaboration with The Innovation Institute. The valve is a respiratory device that facilitates the protection of patients from ventilator-associated pneumonia and caregivers from the risk of infection from opening the ventilator circuit, while also providing optimal inhalation velocity.
The BayWin Valve is positioned within the inner chamber (see video below) where the flow between a manual resuscitation bag port and a ventilator port can be switched, enabling the patient to be treated without having to disconnect the respirator support system to thereby connect the resuscitation bag. Our design ensures that the closed circuit is not compromised during airflow manipulation. The BayWin Valve provides for smooth transitions and automatically reverts back to “normal” ventilation mode once the operator has completed ventilator care. This results in more beneficial patient outcomes and a safer work environment for caregivers.
We have been issued two U.S. patents (6,886,561; 8,656,925) and corresponding patents in Europe and Canada that cover key features of design. The Innovation Lab has also filed a provisional patent to protect recent design improvements. Currently, we are pursuing a dialogue with the experts at Cleveland Clinic for clinical feedback as well as Vyaire Medical and Halyard Health about their commercial interest in this impactful solution.
We are optimistic that our product will be deployed across health systems by early next year. Our hopes are that future long-term, multicenter studies on this device will show that the average patient hospital stay will be shortened, thus having powerful financial implications.
For more information, please visit www.ii4change.com.